Wesley Smith is blogging around the Web on the sad death of a 50 year old Atlanta man whose family took the doctors and hospital to court. Wesley rightly notes the poor communication.
The reporter is indeed a very bad communicator. I wonder about the reliability of the whole story because of the reporter’s description of the patient: “he was brain dead and being kept alive by life support.” While I can believe that the docs used “life support,” the reporter goes on to say that the patient “passed away” when the ventilator was stopped and used the phrase, “pull the plug.”
“Brain dead” patients are not alive and they’re not on “life support.” The doctors are using “artificial support.” for the organs on a dead patient. (See this British Journal of Medicine article and comments, below.) Just as we support the body while waiting for the arrangements for organ donation (or for the birth of a child of a brain dead mother), it is customary to notify the family and give them a chance to “say goodbye” before discontinuing the ventilator and medications supporting the
Way down at the bottom, the article actually says,
“doctors told the family the stroke caused massive bleeding in Donald’s brain. Four different physicians examined Fennell and his brain scans and determined his brain, including the brain stem which controls basic bodily functions like breathing, had ceased to function, according to court and patient records.”
However, the problem started with the nurse who called security to have the family removed from the hospital because Mr. Fennell’s 3 sons,
21, 20 and 18-year-old college football players— cried loudly and shouted “No!” when told their father was brain dead. After that, she said, security guards were posted at the door whenever they visited.”
It’s hard to talk to people who are shouting, but it’s harder to talk to them when they’ve been kicked out of the building.
I’m trying to get my head around the medico-legal problem of delaying the declaration of death by the docs, scheduling a time to turn off the ventilator, and the comment about the machines being broken.
However, people don’t live by laws alone. We often act from our hearts.
The New England Journal of Medicine published a review article describing the determination of death by neurological criteria in 2001. And here’s an excellent (free) article from 2002, from the British Journal of Medicine that actually calls the ventilator and cardiac support “artificial support” and includes the ethical caveat that “”No physician engaged in euthanasia or medically assisted suicide should be responsible for diagnosing brain death.
Not coincidentally, the subject of yesterday’s Secondhand Smoke was the case of an Orthodox Jewish man in Canada. The gentleman is on a ventilator and suffering from the effects of heart failure, pulmonary hypertension and renal failure. Three doctors, including one selected by the family have determined that he is dying and, even without the consent of the patient or the family, decided to remove the ventilator. The family has taken the doctors to court to prevent the removal of the ventilator on religious grounds.
One of the family’s lawyers actually said that removing the ventilator is the same thing as smothering the patient with a pillow, and that (of the docs and nurses who must maintain the ventilator and adjust its settings):
“To do what they are suggesting would involve a physical act,” he said. “You have to touch him, you have to remove the tubes. My reading of the law is that without consent … they can’t do it. I submit that is assault and battery.”
(According to newspaper reports, the docs plan to remove the feeding tube, also. But that’s not relevant, here, since Mr. Golubchuk will die within minutes if he is unable to breathe on his own off the ventilator. If any of the docs are making a fuss about the feeding tube, they are not very wise, since doctors and nurses aren’t needed to maintain or monitor the feedings.)
An article from the Winnipeg newspaper on December 11 says that
“An orthodox rabbi consulted by the family quotes from guidelines on Jewish medical care that say it is imperative for doctors to prolong life, even if the patient is “suffering greatly” and asks for care to stop.”
It’s my understanding that Orthodox law forbids disconnecting the machine until the heart stops, even though there has been talk of a machine in use in Israel to randomly turn off ventilators so that the people won’t have to. But I’ve never read that the Orthodox go so far as to demand that suffering be ignored.
In fact, withholding care under Orthodox Jewish law is acceptable. See the discussion about flickering candles, here. Here’s a very well written review of Orthodox Jewish law on end of life, from the Virtual Mentor, the AMA ethics journal.
Do you suppose the family really believes that they should force other people to cause suffering? The family lawyer does point us to the ethics of intent and consequence of “a physical act.” While the family may have the right to continue their father’s suffering and to prevent the removal of the ventilator they don’t have the right to force any particular doctor, nurse, or tech to act to violate their own conscience by adjusting, cleaning, and monitoring the ventilator.
Surely there’s an Orthodox doc in the area who is willing to care for Mr Goubchuk and his family.
>Most people are ignorant of matters medical. No great surprise there. For even the more educated non-specialists, knowledge of the brain usually reaches its limit at 'Its the thinking organ.' Humans dont think of each other as minds within a brain or as brains within a body – so as far as they are concerned (usually), someone isn't dead until their chest stops moving and their heart stops beating.In regard to the religious aspects, this is something that I have never been able to understand. It makes more sense for Jews, but Christians and most other religions believe in an afterlife – so why the emphesis on protecting life in this one? Why do they fight so hard to prolong a life for every last moment? I would have thought that an afterlife would actually devalue the material life – it makes no sense to keep a believer tied down in suffering, when Heaven awaits upon their death.
>There's all sorts of nuances – and quirks – to explain the resistance to allowing (without ever causing) the end of life. The common thread is that life is a gift of God. There are also some who see suffering as a virtue in itself – either by purifying, by mirroring the suffering of Christ or for some kind of punishment (that ignores that the Bible tells us that the "rain falls on the just and the unjust). While I believe that patients and loved ones can learn from suffering, I'm not someone that says we should seek out suffering. But we don't end suffering by ending the sufferer. Neither do we prolong suffering artificially or forcing a patient to endure until we've used every tool and medicine currently available and we absolutely can't keep them alive anymore. There are times to let go.Many people see the purpose of medicine as keeping people alive at all costs in addition to curing and healing. I believe that the Hippocratic "First Principle" is to "heal when possible, but first do no harm." When medicine begins to treat the family members or when organs and tissues are failing faster than we can maintain, much less heal, it's time to change the focus of our care to the comfort of the patient without tests, interventions and procedures that are usually thought to do what we've determined we can't do (heal).Unfortunately there are enough doctors who buy in to the idea that some lives aren't worth living and/or that the "choice" to live or not to live is morally equal to that first principle. Autonomy has trumped non-maleficence and "autonomy" can mean the substituted judgment of surrogates when the patient (or embryo or fetus) can't judge for himself.Then there's the power struggle – which is partly due to doctors' history of patronizing treatment of patients, doctors' failure to be perfect and all-powerful (ironic, huh?) and simply because patients and their families what to be in charge, to take control. I'm not sure which came first, but I'm certain that some of the people who seem to want everything their way, or settled in court simply hate doctors and what we do and know.In the end, we are the ones who do know and whose actions are in dispute. Despite what people like Julian Savulescu say (I'll post on his comments in this month's American Journal of Bioethics over the weekend), we can't actually be forced to act – only threatened and punished for not acting.